Provider Demographics
NPI:1679633119
Name:FISK, BRYAN ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:ALEXANDER
Last Name:FISK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:600 N UNION AVENUE
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-4194
Practice Address - Country:US
Practice Address - Phone:830-606-9111
Practice Address - Fax:210-703-0934
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9854207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283804701Medicaid
TX283804701Medicaid